There are many reasons you became a health care professional. Feeling helpless isn’t one of them. But when you’re looking down at a critically injured patient and the only thing that will save his life is the medical history you don’t have or when you’re desperately trying to find your dying patient’s family before it’s too late, helpless is exactly what you feel. What if you could find his family and medical history quickly and easily and reduce liability and increase patient safety?

Tuesday, July 07, 2009

Have you noticed how many primetime medical shows are doing episodes on next of kin notification issues? Just in the last two months there have been two – “Grey’s Anatomy” on ABC and the new TNT series “HawthoRNe”. Not that they meant to do episodes specifically about that, and as far as one of the series goes, that central theme was completely glossed over, even though a next of kin issue was pivotal to a central character’s survival.

Now I love “Grey’s Anatomy” – always have. And as a television writer myself, (who also happens to run a non profit organization that deals with family safety and patient notification issues), I’m always interested to see how those important themes play out in the drama of an episode. As most fans of the series know, the last two episodes of the season revolved around Izzy fighting for her life following cancer surgery and George O’Malley who, during the first half of the episode, decides to go off and join the Army to treat injured soldiers in Iraq. He then disappeared, as we later found, to say goodbye to his family before heading off to serve his country. In case you’re one of the ten or twenty people in America who didn’t see the episode, I’ll insert a spoiler alert. So if you haven’t seen the episode yet but plan to, skip down a few paragraphs.

A few scenes later an unidentified man is rushed into the emergency department. Hailed a hero, the man was hit by a bus after pushing a woman out of its path. The patient was a mess. He had a massive head injury, was covered in blood, his arm was nearly torn off and before he knew it, had the best residents of Seattle Grace looking down at him with pity. They doubted he would last the night, but they did what they always do and gave it their best. IVs were started, surgery was scheduled and they did a pretty decent job of caring for him.

Except for one thing.

No one, and I mean no one, not even Lexi the patient-loving intern, visibly searched for his ID.

Granted the man was run over and dragged by a bus, so finding his ID might have been a challenge, but he was still clearly wearing clothes. The writers could have easily put in a throwaway line to show them doing the right thing, like “I found a driver’s license, but it’s completely saturated with blood” or “this looks like an ID badge, but it’s crushed and completely unreadable. At least they would have not only given a nod to proper trauma procedure, but to the fact that the patient lying close to death was a human being. What if they were about to give him a drug he was deathly allergic to, or that was about to interact with something else he was already taking? What about the fact that this patient had people he loved and who loved him, who needed to know that he might not live through the night?

By the end of the episode, they were doing everything they could to save this patient. He was stable but still very critical. For the second or third time the man tried to talk, to no avail. Meredith leaned in, and the patient grabbed her hand. He started drawing on it with one of his only good fingers. Zero, zero and a seven. 007. George. He instantly went from being a John Doe to a much-loved friend. In that moment, Meredith’s eyes and scream told the whole story. It was the difference between taking care of someone you know, with his or her needs in mind – even if the only way you “know” them is by reading their medical history and talking with their family – and someone who is just another person or worse just another patient. They took incredibly good care of George even when they didn’t know who he was, but from our own experiences with my grandma’s hospitalization, when the hospital didn’t bother to call us for several days to tell us that she’d been admitted and was becoming more critical by the minute, the step of looking for identification and trying to locate a patient’s identity and next of kin, is just too vital to be glossed over like this. “Grey’s Anatomy” had the perfect opportunity to show how it should be done, and missed it. They usually do a terrific job, but this one decision was disappointing.

Now over on TNT’s new series “HawthoRNe”, they did a different twist on a next of kin issue. Nurse Hawthorne’s patient is alone and his wife isn’t yet on scene. He has a brain injury that will require surgery and is altered – meaning that he doesn’t really know what’s going on around him. While Hawthorne is treating him, he mistakes her for his wife and confesses that he has been having an affair. The man’s injuries intensify – he’ll need surgery – but of course he has a DNR. Hawthorne wants to make sure that her patient has the opportunity to see his wife before surgery to provide closure to both of them in case he doesn’t make it. The man codes. Now with a DNR, she’s supposed to stand aside, respect his decision and not resuscitate him. But his wife is going to be there any moment. Hawthorne is thinking about this patient as a human being and realizes how important closure could be to both her patient and his wife. The doctors standing around her keep telling her that he’s too far gone and just to let nature take its course. But she risks her career and her reputation, by grabbing the paddles herself and shocking him back to life, much to the chagrin of the doctors. The patient is able to talk to his wife and he survives his surgery. Why? Because a nurse treated a patient who on paper wasn’t mentally competent and who had chosen not to be resuscitated, as a human being who had a history, people who loved him and in this case, extenuating circumstances that could alter the rest of his wife’s life. A difficult issue was raised and handled in a way that was respectful to the patient, his family and the medical profession.

The one thing that the producers of medical shows need to realize is that a lot of health care professionals out there are watching. Not that anyone takes their cue on how to provide patient care from a television series. But it wouldn’t hurt to get the basics right like showing the search for an unidentified patient’s ID. Not only would we as viewers feel like everything that could be done for the patient, had been done, but it would serve as a reminder to all those health care professionals out there, of how important it is to quickly identify a patient to be able to treat him with his specific needs in mind, and not just as a body. And who knows? That two second scene of Meredith or Lexi searching for an ID that’s completely torn apart and unreadable, would have intensified the drama even more, because they’d have us all asking “who is this person and how in the world are they ever going to discover his identity?”

Thanks producers for all the excellent work you do on incredibly difficult subjects week after week. All we ask is that you look after the basics too :-)

As we’ve found in our own lives, as basic as it sounds, taking the time to identify the actual problem is a much better start than just jumping in and trying to solve them. As founders of the Next of Kin Education Project (http://www.nokep.org/), our attention was immediately drawn to the paragraphs on Quality of Care. According to the editorial:

“Dedicating so much of the economy to healthcare might be acceptable if the investment yielded the world's best results, but it doesn't. Despite spending far more per person and a far higher percentage of GDP than any other country, the U.S. lags behind other industrialized nations on most measurements of healthcare. These include higher death rates from medical errors and treatable diseases, and higher infant mortality, according to a 2006 study by the Commonwealth Fund. Defenders of the U.S. system often argue that patients in other countries face lengthy delays for care, especially from specialists or for elective surgeries. But the Commonwealth Fund study found that, compared with several other countries, "U.S. patients are notably less likely to have rapid (same- or next-day) access to physicians when sick or to find it easy to get care after hours without going to the emergency room."Even within the United States, there seems to be only a tenuous relationship between the amount of money spent on patients and the quality of care. Researchers at Dartmouth Medical School have looked at Medicare spending across the country, finding wide variation in the cost -- and, frequently, better results in regions where spending was lower. Nor have U.S. healthcare providers coordinated care for individual patients or helped them manage chronic diseases as well as their counterparts in other industrialized nations. Part of the problem is the slow, haphazard adoption of information technology, including digitized medical records, to guide patient care and prevent errors. Studies by the Rand Corp. in 2003 and 2006 found that U.S. patients receive the right care only about 55% of the time, and that the problem affects rich and poor, insured and uninsured alike.”

I’d like to add one more point to the discussion. Healthcare spending is often wasted on the repercussions of medical errors and simple mistakes that can easily be prevented. We had an experience in our family where my grandmother was hospitalized, yet the hospital didn’t call my mother and I, to tell us that she had fallen at home and had been admitted. By the time we found out, she'd been given drugs that interacted with those she was prescribed simply because they didn't call us to get a medical history.

Not only did that mistake end up costing Grandma her life, and us the chance to get to her bedside before her death, it cost the hospital itself unnecessary liability and the increased costs of intensive and cardiac care that would not have been necessary if one simple phone call had been made. In her memory, our solution was to create a next of kin notification training program that hospitals across the country are now adopting. But when problems that simple are identified, additional training, is a simple yet effective way of stemming unnecessary cost drains on our healthcare system.

Sunday, June 14, 2009

We’ve all seen patients who were far beyond the reach of medical treatment suddenly defy the odds and recover. We’ve also seen patients who were well on the road to recovery, take a turn for the worse for seemingly no reason at all. No matter what the technology or how terrific we are at our jobs, sometimes medicine just isn’t enough.

Case in point, a few years ago, my Grandma, in her mid-sixties at the time, had a moderate CVA. No matter what her doctors did for her, she wasn’t regaining consciousness, defying explanation. My mom and I were living and working in Los Angeles and Grandma was two thousand miles away in Chicago. When the doctor called to tell us about the stroke, he not only said that Grandma might not live through the night, but that she might not last the few hours it would take us to fly to her side. Mom and I both felt very strongly that we had to talk to her for what might be the last time, before we got on the plane. Hearing our voices and knowing that someone was with her, had always made a huge difference in any difficulty she faced. So Mom got the head nurse on the phone and asked if she could get a phone to Grandma. Asking quickly turned to pleading – we needed to tell Grandma to hold on and that we were coming.

The nurse basically dismissed the notion – what possible good could THAT do? It took a while, but Mom finally convinced the nurse to put a phone up to Grandma’s ear. We were able to tell her how much we loved her, that she was going to be fine and that we were on our way. By the time the nurse came back on the phone, she was speechless. Evidently the moment Grandma heard our voices her eyelids began to flutter. Her vitals stabilized, her eyes opened for the first time since she’d been in the hospital and she looked straight up at the nurse and then around the room looking for us. Two weeks later, she was out of the hospital and on her way to rehab.

That’s the miracle of communication.

Whether it’s a family member, a friend or just a familiar face, patients need to have the people they love surrounding them, when they’re ill, in pain, or afraid. As caregivers, it’s part of the job to realize that patients might be too ill or physically unable to initiate the contact they so desperately need, on their own.

I wish that were the end of the story. A few years later, Grandma who had recovered fully, badly injured her leg and her jaw after falling in the bathroom at home. She was unable to speak but was in stable condition, when admitted to a different hospital. She was supposed to have gone on vacation so we hadn’t expected to hear from her and had no idea she was in the hospital. A few days later she began spiraling into critical condition. By the time the hospital called us, she was in the ICU, unconscious and critical. While I was on one phone trying to get a flight, my mom was on the other phone with the doctor who happened to be standing right outside Grandma’s room. She begged him and then the nursing staff, to get a phone into her, so she could talk to her, for what looked like it would be the last time.

But at this hospital, the doctor and the nurses refused. While the doctor was on the phone with mom, Grandma, who had been unconscious just a few minutes before, unexpectedly opened her eyes and began to look around. The doctor told Mom what happened and took this as a sign that she her condition was turning around. Even so, Mom still pleaded with him to get a phone to Grandma. He told her there was no way to get a phone to an ICU patient. “We’ll try and figure something out in the morning,” he said, hanging up the phone. But Grandma didn’t have until morning. She died just a few hours later, before we could get to her and we lost our chance to tell her we loved her – our chance to say goodbye.

Looking back on that time reminds me of that scripture, “without a vision, the people perish”. Some people, even while facing serious illness or death are so self-motivated that just the possibility of dying makes them muster every ounce of strength they have, to fight it. But most people aren’t that way. Most people need to use the strength of others – the people they love – to provide the strength they cannot find.

Patients need connection. They need vision – the vision to “see” themselves getting through the darkness and fear that they’re facing. They need help “seeing” the next day or the next week. Seeing themselves strong and well again. And without that strength and that support they so desperately need from the people they love, there is no vision. And without that vision, they perish.

Simply put, at that moment, Grandma needed us. She needed to hear our voices that night and the very people who were there to be her advocates and to help her make that connection happen, didn’t do it. And that night, Grandma perished, without knowing that we were right there at the other end of that phone and on our way to be with her.

The good news is, the same thing that happened to us, doesn’t have to happen at your facility. With just a few simple steps designed to help communication-impaired patients, you can not only make a huge difference in their lives, you might even save them.

With just a few simple steps designed to help communication-impaired patients, you can make a huge difference in their lives. How? Stay Tuned

About Us

Mother and daughter screenwriting team Laura and Janet Greenwald have been helming The Next of Kin Education Project since 2002. NOKEP began after Jan’s mother Elaine died at the hands of a Chicago hospital due to massive negligence. The hospital failed to notify them that Elaine had even been hospitalized, for days. By the time they were notified it was too late, and Elaine died unnecessarily and alone. After finding out there were no laws in Illinois or California making next of kin notification mandatory, the duo created and enacted three Next of Kin Laws in both states.
Jan and Laura then joined forces with medical experts to create The Seven Steps Notification System which gives hospitals the tools they need to perform NOK notifications quickly and easily in almost any situation. Last year they used the background and tools gained through NOKEP to create the Safe Family and Safe Student Action Plans to help families and college students everywhere locate, use and secure their emergency medical information and vital documents into a Grab and Go format they can take with them at a moment's notice – because life, after all, doesn’t come with a pause button.